Crease disappeared after ptosis repair, could a revisional surgery recreate a crease? (photo)

Question

I had surgery 11 months ago to repair a congenital left ptosis, with minor blepharoplasty. I no longer have a definitive eyelid crease, and feel I look more assymetrical now than before surgery. I also feel that I still have some residual ptosis.  I look forward to any advice..

Damien Grinsell MBBS, FRACS (Plast) · Answer

Hi. I don't think you have a residual ptosis however there are some things about your eyelid aesthetics that could be improved. The crease can be remade by anchoring the skin to the top of the tarsal plate. You also have a slight excess of skin on the right which could benefit from a skin only excision.  The major thing that I see is that you eyes tend to tilt downwards on the outer side which gives you a sad expression.  This is harder to fix but the lateral canthal tendon can be adjusted and moved into a higher position.Hope this helpsDamien

Matheson A. Harris, MD · Answer

It is hard to tell from the photo, but the type of surgery you had for ptosis repair may not have created a lid crease for you. When surgery is done from the inside of the eyelid (posterior repair), a small muscle is shortened to raise the eyelid. This muscle is not one that creates the fold in your skin and so won't make your lid crease. Ptosis repair done through a skin incision, where the levator muscle is adjusted, can create a defined lid crease when closed properly. I'd speak with your eyelid surgeon about this. If he/she feels a revision is in order, an external repair with lid crease formation could achieve the result you are looking for.

Amiya Prasad, MD - Account Suspended · Answer

Thank you for your question. You submitted a single photo, describing a history of ptosis surgery for congenital ptosis about 11 months ago. You are concerned about the absence of a defined crease on the left eye and some residual ptosis. You also feel you are more asymmetric than you were prior to surgery, so you are looking for some guidance on what to do.
I can share with you how I evaluate my patient with similar situations in my practice. A little background: I’m a Board-certified cosmetic surgeon and fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years, and ptosis surgery is one of the most common procedures we do. I can give you some ideas, but there is probably some benefit related if I had additional information about your congenital ptosis. 
First, congenital ptosis means you were born with this ptosis the muscle that lifts the eyelid called the levator muscle didn’t develop properly. There is a spectrum of the congenital issue based on the level of the eyelid relative to the pupil from mild, moderate, to severe, and the amount of muscle function in how well the levator contracts. You can have anywhere from minimal function/zero function/zero millimeters of movement, to excellent muscle function. Based on that combination, a ptosis surgeon will then determine how to do your operation. 
In our practice, for adults, depending on their type of ptosis, the majority of our patients will have the procedure under local anesthesia with LITE™ sedation. One of the biggest challenges of ptosis surgery is trying to achieve the optimal height and contour to maximize symmetry, so during surgery, we sit the patient up to see their eyelid levels, and do a comparison to make sure we achieve the optimal goal. 
To address the issue about the eyelid crease, this is based on an amount of skin available to fold over. When you look at your right eye there is a little hooding or extra skin, and on the operated left eye, the operated eye, there is very little additional skin. So the question that first comes into mind, since you didn’t have a blepharoplasty, is about the extra skin. This means you likely had skin removed to try to improve the hooding on that eye. When that occurs, it is clear that there is a difference between the amount of skin over your eyes, which I think is the core issue of asymmetry. 
When we are trying to do an operation like this where the person doesn’t want to have blepharoplasty in the eye where there is extra skin, then very limited blepharoplasty is typically undertaken. At times, I will try to avoid removing any skin at all, but use the eyelid crease to enter this space to address the levator muscle. This is analogous to what we do for Asian eyelid surgery with the intention is to create a crease. It is critical to maintain a certain amount of extra skin so there is a fold which can overlap and create a natural crease. 
In terms of the eyelid level achieved, looking at your photo, the symmetry there, which I determine by looking at the eyelid margin relative to the pupil, to the center of the pupil. What I typically explain to every patient who’s going to have unilateral ptosis surgery is the goal is to maximize symmetry - we want to get you as close to the other eye as possible. However, it’s important to understand that within a rthe general population, people without clinical diagnosis of ptosis, the norm to have both eyes to have up to a 2 millimeter difference between them, and it still looks natural and symmetric -the human body is beautifully imperfect. When we talk to patients about doing fillers, volume augmentation, or facelifts, I always explain how one side of the face is different than the other. 
For the height of your eyelid margin relative to the pupil, you are probably as close as could be expected, so there is probably no additional value in more surgery. However, a solution worth considering to maximize symmetry is a contralateral blepharoplasty in the right eye to have more balance between the two eyes, which I’m sure was probably discussed with your doctor prior to surgery. In terms of trying to create a crease, the limitation in this situation is how much skin is available to fold over. Based on the photo you submitted, it doesn’t look like there is enough skin, so even if a crease was to be anchored to try to define the crease, the anatomy of the shape of the eye socket and the amount of skin available is likely to limit any meaningful change with any surgery. 
I think the overall issue with the asymmetry is more about the asymmetry between the hooding on one eye, compared to the absence of hooding on the other eye. If the goal is to have better symmetry, then I suggest considering having a right upper eyelid blepharoplasty. 
I think it’s very important to have this discussion with the operating surgeon. I think your overall result, if the goal of the ptosis surgery was to lift the eyelid, based on this photo, your objective has been achieved. To maximize cosmetic symmetry, consider the right upper eyelid blepharoplasty. I hope that was helpful, I wish you the best of luck, and thank you for your question.This personalized video answer to your question is posted on RealSelf and on YouTube. To provide you with a personal and expert response, we use the image(s) you submitted on RealSelf in the video, but with respect to your privacy, we only show the body feature in question so you are not personally identifiable. If you prefer not to have your video question visible on YouTube, please contact us.

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